Quality of life after total laparoscopic hysterectomy versus total abdominal hysterectomy for stage I endometrial cancer (LACE) : a randomised trial

Background: The two-stage Total Laparoscopic Hysterectomy (TLH) versus Total Abdominal Hysterectomy (TAH) for stage I endometrial cancer (LACE) randomised controlled trial was initiated in 2005. The primary objective of stage 1 was to assess whether TLH results in equivalent or improved QoL up to 6 months after surgery compared to TAH. The primary objective of stage 2 was to test the hypothesis that disease-free survival at 4.5 years is equivalent for TLH and TAH. Results addressing the primary objective of stage 1 of the LACE trial are presented here. Methods: The first 361 LACE participants (TAH n= 142, TLH n=190) were enrolled in the QoL substudy at 19 centres across Australia, New Zealand and Hong Kong, and 332 completed the QoL analysis. Randomisation was performed centrally and independently from other study procedures via a computer generated, web-based system (providing concealment of the next assigned treatment) using stratified permuted blocks of 3 and 6, and assigned patients with histologically confirmed stage 1 endometrioid endometrial adenocarcinoma and ECOG performance status <2 to TLH or TAH stratified by histological grade and study centre. No blinding of patients or study personnel was attempted. QoL was measured at baseline, 1 and 4 weeks (early), and 3 and 6 months (late) after surgery using the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire. The primary endpoint was the difference between the groups in QoL change from baseline at early and late time points (a 5% difference was considered clinically significant). Analysis was performed according to the intention-to-treat principle using generalized estimating equations on differences from baseline for the early and late QoL recovery. The LACE trial is registered with clinicaltrials.gov (NCT00096408) and the Australian New Zealand Clinical Trials Registry (CTRN12606000261516). Patients for both stages of the trial have now been recruited and are being followed up for disease-specific outcomes. Findings: The proportion of missing values at the 5%, 10% 15% and 20% differences in the FACT-G scale was 6% (12/190) in the TLH and 14% (20/142) in the TAH group. There were 8/332 conversions (2.4%, 7 of which were from TLH to TAH). In the early phase of recovery, patients undergoing TLH reported significantly greater improvement of QoL from baseline compared to TAH in all subscales except the emotional and social well-being subscales. Improvements in QoL up to 6 months post-surgery continued to favour TLH except for the emotional and social well-being of the FACT and the visual analogue scale of the EuroQoL five dimensions (EuroQoL-VAS). Length of operating time was significantly longer in the TLH group (138±43 mins), than in the TAH group at (109±34 mins; p=0.001). While the proportion of intraoperative adverse events was similar between the treatment groups (TAH 8/142, 5.6%; TLH 14/190, 7.4%; p=0.55), postoperatively, twice as many patients in the TAH group experienced adverse events of CTC grade 3+ than in the TLH group (33/142, 23.2% and 22/190, 11.6%, respectively; p=0.004). Postoperative serious adverse events occurred more frequently in patients who had a TAH (27/142, 19.0%) than a TLH (15/190, 7.9%) (p=0.002). Interpretation: QoL improvements from baseline during early and later phases of recovery, and the adverse event profile significantly favour TLH compared to TAH for patients treated for Stage I endometrial cancer.

Childhood experiences of cancer : an interpretative phenomenological analysis approach

Pediatric oncology has emerged as one of the great medical success stories of the last 4 decades. The cure rate of childhood cancer has increased from approximately 25% in the 1960’s to more than 75% in more recent years. However, very little is known about how children actually experience the diagnosis and treatment of their illness. A total of 9 families in which a child was diagnosed with cancer were interviewed twice over a 12-month period. Using the qualitative methodology of interpretative phenomenological analysis (IPA), children’s experiences of being patients with a diagnosis of cancer were explicated. The results revealed 5 significant themes: the experience of illness, the upside of being sick, refocusing on what is important, acquiring a new perspective, and the experience of returning to wellbeing. Changes over time were noted because children’s experiences’ were often pertinent to the stage of treatment the child had reached. These results revealed rich and intimate information about a sensitive issue with implications for understanding child development and medical and psychosocial treatment.

From Jindabyne to 'Jindabyne' : immigrant and indigenous specters

This paper reads Ray Lawrence's film Jindabyne (2006) in order to consider how "Australian" connotes as "immigrant" or "Indigenous" in contemporary Australia. Although the film is an adaptation of an American short story, it exploits an existing grammar of place in Australian cultural production in order to interrogate this very culture. If questions of race, gender, and class have haunted post-settlement Australia, Lawrence's film simultaneously stages these spectres and gestures towards the necessary failure of any attempt to exorcise them in a place where indigeneity is invisible. Thus, the location of Jindabyne, the town drowned in the name of progress, offers an exemplary visual metaphor for the failed project of identity formation in a place where forgetting is a survival tool.

Researching the 'reception' of indigenous affairs in Australia

The Reporting and Reception of Indigenous Issues in the Australian Media was a three year project financed by the Australian government through its Australian Research Council Large Grants Scheme and run by Professor John Hartley (of Murdoch and then Edith Cowan University, Western Australia). The purpose of the research was to map the ways in which indigeneity was constructed and circulated in Australia's mediasphere. The analysis of the 'reporting' element of the project was almost straightforward: a mixture of content analysis of a large number of items in the media, and detailed textual analysis of a smaller number of key texts. The discoveries were interesting - that when analysis approaches the media as a whole, rather than focussing exclusively on news or serious drama genres, then representation of indigeneity is not nearly as homogenous as has previously been assumed. And if researchers do not explicitly set out to uncover racism in every text, it is by no means guaranteed they will find it1. The question of how to approach the 'reception' of these issues - and particularly reception by indigenous Australians - proved to be a far more challenging one. In attempting to research this area, Hartley and I (working as a research assistant on the project) often found ourselves hampered by the axioms that underlie much media research. Traditionally, the 'reception' of media by indigenous people in Australia has been researched in ethnographic ways. This research repeatedly discovers that indigenous people in Australia are powerless in the face of new forms of media. Indigenous populations are represented as victims of aggressive and powerful intrusions: ‘What happens when a remote community is suddenly inundated by broadcast TV?’; ‘Overnight they will go from having no radio and television to being bombarded by three TV channels’; ‘The influence of film in an isolated, traditionally oriented Aboriginal community’2. This language of ‘influence’, ‘bombarded’, and ‘inundated’, presents metaphors not just of war but of a war being lost. It tells of an unequal struggle, of a more powerful force impinging upon a weaker one. What else could be the relationship of an Aboriginal audience to something which is ‘bombarding’ them? Or by which they are ‘inundated’? This attitude might best be summed up by the title of an article by Elihu Katz: ‘Can authentic cultures survive new media?’3. In such writing, there is little sense that what is being addressed might be seen as a series of discursive encounters, negotiations and acts of meaning-making in which indigenous people — communities and audiences —might be productive. Certainly, the points of concern in this type of writing are important. The question of what happens when a new communication medium is summarily introduced to a culture is certainly an important one. But the language used to describe this interaction is a misleading one. And it is noticeable that such writing is fascinated with the relationship of only traditionally-oriented Aboriginal communities to the media of mass communication.

Revitalizing health for all : international Indigenous representative group. Learning from the experience of comprehensive primary health care in Aboriginal Australia — A commentary on three projects

This paper presents a regional commentary (hereafter ‘the commentary’) on the three Australian projects of the Teasdale-Corti Global Health Research Partnership Program. The three Australian projects are: Victorian Aboriginal Health Service Ltd (VAHS), Melbourne, Victoria—Forty Years of Comprehensive Primary Health Care; Central Australian Aboriginal Congress Inc. (Congress), Alice Springs, Northern Territory—Ingkintja, Male Health Program; and Urapuntja Health Service (UHS), Utopia, Northern Territory—Outstation Health Care. It highlights common themes and lessons in respect to the Revitalising Health for All project in the context of Aboriginal and Torres Strait Islander health in Australia.

On the contemporary position of the Indigenous peoples of Australia

This paper highlights the contemporary disadvantaged position of Indigenous peoples of Australia.∗ It discusses a number of data quality issues on Indigenous data, before examining Indigenous disadvantage across five key areas: (1) education; (2) employment; (3) housing and living conditions; (4) health and wellbeing; and (5) crime and justice. Given the call for all governments to implement a framework to overcome Indigenous disadvantage, we recommend that future research begin with an investigation of non-Indigenous attitudes towards, and knowledge of, the position of Indigenous peoples in Australia. This is essential towards developing an understanding of the general public’s current perceptions of Indigenous peoples’ position in Australia, particularly where the development of policies pertaining to Indigenous peoples requires cooperative action and the support of the broader Australian population.

Cardiac ARIA Index: Measuring Accessibility to Cardiovascular Services in Rural and Remote Australia via Applied Geographic Spatial Technology

Cardiovascular disease (CVD) continues to impose a heavy burden in terms of cost, disability and death in Australia. Evidence suggests that increasing remoteness, where cardiac services are scarce, is linked to an increased risk of dying from CVD. Fatal CVD events are reported to be between 20% and 50% higher in rural areas compared to major cities. The Cardiac ARIA project, with its extensive use of geographic Information Systems (GIS), ranks each of Australia’s 20,387 urban, rural and remote population centres by accessibility to essential services or resources for the management of a cardiac event. This unique, innovative and highly collaborative project delivers a powerful tool to highlight and combat the burden imposed by cardiovascular disease (CVD) in Australia. Cardiac ARIA is innovative. It is a model that could be applied internationally and to other acute and chronic conditions such as mental health, midwifery, cancer, respiratory, diabetes and burns services. Cardiac ARIA was designed to: 1. Determine by expert panel, what were the minimal services and resources required for the management of a cardiac event in any urban, rural or remote population locations in Australia using a single patient pathway to access care. 2. Derive a classification using GIS accessibility modelling for each of Australia’s 20,387 urban, rural and remote population locations. 3. Compare the Cardiac ARIA categories and population locations with census derived population characteristics. Key findings are as follows: • In the event of a cardiac emergency, the majority of Australians had very good access to cardiac services. Approximately 71% or 13.9 million people lived within one hour of a category one hospital. • 68% of older Australians lived within one hour of a category one hospital (Principal Referral Hospital with access to Cardiac Catheterisation). • Only 40% of indigenous people lived within one hour of the category one hospital. • 16% (74000) of indigenous people lived more than one hour from a hospital. • 3% (91,000) of people 65 years of age or older lived more than one hour from any hospital or clinic. • Approximately 96%, or 19 million, of people lived within one hour of the four key services to support cardiac rehabilitation and secondary prevention. • 75% of indigenous people lived within one hour of the four cardiac rehabilitation services to support cardiac rehabilitation and secondary prevention. Fourteen percent (64,000 persons) indigenous people had poor access to the four key services to support cardiac rehabilitation and secondary prevention. • 12% (56,000) of indigenous people were more than one hour from a hospital and only had access one the four key services (usually a medical service) to support cardiac rehabilitation and secondary prevention.

Association between prostinogen (KLK15) genetic variants and prostate cancer risk and aggressiveness in Australia and a meta-analysis of GWAS data

Background: Kallikrein 15 (KLK15)/Prostinogen is a plausible candidate for prostate cancer susceptibility. Elevated KLK15 expression has been reported in prostate cancer and it has been described as an unfavorable prognostic marker for the disease. Objectives: We performed a comprehensive analysis of association of variants in the KLK15 gene with prostate cancer risk and aggressiveness by genotyping tagSNPs, as well as putative functional SNPs identified by extensive bioinformatics analysis. Methods and Data Sources: Twelve out of 22 SNPs, selected on the basis of linkage disequilibrium pattern, were analyzed in an Australian sample of 1,011 histologically verified prostate cancer cases and 1,405 ethnically matched controls. Replication was sought from two existing genome wide association studies (GWAS): the Cancer Genetic Markers of Susceptibility (CGEMS) project and a UK GWAS study. Results: Two KLK15 SNPs, rs2659053 and rs3745522, showed evidence of association (p, 0.05) but were not present on the GWAS platforms. KLK15 SNP rs2659056 was found to be associated with prostate cancer aggressiveness and showed evidence of association in a replication cohort of 5,051 patients from the UK, Australia, and the CGEMS dataset of US samples. A highly significant association with Gleason score was observed when the data was combined from these three studies with an Odds Ratio (OR) of 0.85 (95% CI = 0.77-0.93; p = 2.7610 24). The rs2659056 SNP is predicted to alter binding of the RORalpha transcription factor, which has a role in the control of cell growth and differentiation and has been suggested to control the metastatic behavior of prostate cancer cells. Conclusions: Our findings suggest a role for KLK15 genetic variation in the etiology of prostate cancer among men of European ancestry, although further studies in very large sample sets are necessary to confirm effect sizes.

A multilevel investigation of inequalities in clinical and psychosocial outcomes for women after breast cancer

Background In Australia, breast cancer is the most common cancer affecting Australian women. Inequalities in clinical and psychosocial outcomes have existed for some time, affecting particularly women from rural areas and from areas of disadvantage. We have a limited understanding of how individual and area-level factors are related to each other, and their associations with survival and other clinical and psychosocial outcomes. Methods/Design This study will examine associations between breast cancer recurrence, survival and psychosocial outcomes (e.g. distress, unmet supportive care needs, quality of life). The study will use an innovative multilevel approach using area-level factors simultaneously with detailed individual-level factors to assess the relative importance of remoteness, socioeconomic and demographic factors, diagnostic and treatment pathways and processes, and supportive care utilization to clinical and psychosocial outcomes. The study will use telephone and self-administered questionnaires to collect individual-level data from approximately 3, 300 women ascertained from the Queensland Cancer Registry diagnosed with invasive breast cancer residing in 478 Statistical Local Areas Queensland in 2011 and 2012. Area-level data will be sourced from the Australian Bureau of Statistics census data. Geo-coding and spatial technology will be used to calculate road travel distances from patients' residence to diagnostic and treatment centres. Data analysis will include a combination of standard empirical procedures and multilevel modelling. Discussion The study will address the critical question of: what are the individual- or area-level factors associated with inequalities in outcomes from breast cancer? The findings will provide health care providers and policy makers with targeted information to improve the management of women with breast cancer, and inform the development of strategies to improve psychosocial care for women with breast cancer.